Basic Information
| Provider Information | |||||||||
| NPI: | 1982655536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAWSON | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VANDERPOLS | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NNP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5900 BYRON CENTER AVE SW | ||||||||
| Address2: | MEDICAL ADMINISTRATION | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162523243 | ||||||||
| FaxNumber: | 6162520260 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 BYRON CENTER AVE SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495199606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162527184 | ||||||||
| FaxNumber: | 6162526218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 02/05/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | 161098-1 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 363LN0000X | 4704146251 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
No ID Information.